1. Purpose and Voluntary Nature
This Consent governs optional MedLocker programs involving research, life sciences, analytics, clinical trial matching, surveys, data licensing, compensation, and recontact. You do not need to sign this Consent to use core MedLocker features unless a specific optional program requires it. Your healthcare providers, health plans, and Alpine Labs will not condition treatment, payment, enrollment, or core MedLocker access on signing this optional Consent.
2. Program Types
Select
Program Type
Description
De Identified or Aggregated Analytics
Use or disclose information processed to remove direct identifiers, or aggregated with many users, for research, life sciences, public health, product development, analytics, reporting, or commercial purposes.
Limited or Pseudonymized Data Programs
Use or disclose information with direct identifiers removed but codes, tokens, dates, geography, or limited information retained for longitudinal analysis, matching, or quality controls.
Identifiable Data Sharing
Disclose identifiable health information to named recipients or defined recipient categories for a stated purpose. Program details are required before activation.
Surveys and Interviews
Invite me to answer surveys, participate in interviews, provide patient experience information, or respond to follow up questions.
Clinical Trial or Study Matching
Use my information to identify potential eligibility for trials, registries, observational studies, or care programs, and contact me or share information as authorized.
Recontact and Longitudinal Follow Up
Permit Alpine Labs or approved partners to ask follow up questions over time.
Compensated Programs
Permit participation in programs where Alpine Labs, I, or both may receive compensation according to program terms.
3. Program Details Required Before Identifiable Sharing
Recipient or category of recipient.
Purpose of disclosure.
Categories of data involved.
Whether data is identifiable, de identified, aggregated, limited, pseudonymized, or tokenized.
Whether recontact is permitted and by whom.
Whether compensation is involved and how it is handled.
Duration or expiration.
Withdrawal process and material risks or special privacy terms.
4. Categories of Data
- Demographic and profile information.
- Diagnoses, conditions, symptoms, procedures, medications, allergies, immunizations, labs, imaging, vitals, encounters, care plans, and notes.
- Claims, insurance, eligibility, benefits, EOBs, costs, utilization, and payment information.
- Device, wearable, app, survey, patient reported, caregiver reported, and outcome information.
- Sensitive categories only if permitted by program details and applicable law, including mental health, substance use disorder, HIV/AIDS, genetic, reproductive health, family planning, and STI records.
- Other: ____________________________________________
5. Categories of Recipients
- Academic researchers or nonprofit research organizations.
- Life sciences, pharmaceutical, biotechnology, medical device, and diagnostics companies.
- Healthcare providers, health systems, care delivery organizations, or clinical research sites.
- Health plans, payer organizations, benefit administrators, or value based care organizations.
- Public health, patient advocacy, registry, or disease foundation organizations.
- Analytics, data science, software, or health technology companies.
- Other named recipient: ____________________________________________
6. Compensation, De Identification, and Sale
Some programs may involve compensation to Alpine Labs, to me, to a caregiver, to a research site, or to another participant. Program details will explain material compensation terms before participation. Unless a program states otherwise, I am responsible for taxes and payment account accuracy related to compensation I receive.
De identified, aggregated, limited, pseudonymized, or tokenized data reduces privacy risk but may not eliminate all risk. Alpine Labs will use controls designed to reduce re identification risk and will require appropriate recipients not to attempt re identification where applicable. If any program is considered a sale of consumer health data under applicable law, Alpine Labs will obtain any required separate written authorization before the sale.
7. No Medical Advice, Withdrawal, and Expiration
Data programs are not medical advice, diagnosis, treatment, or emergency services. I may withdraw future participation by using MedLocker controls or contacting privacy@alpinelabs.ai. Withdrawal will stop future use or disclosure that depends on this Consent after Alpine Labs processes the request, but may not affect information already disclosed, used, relied upon, included in completed analyses, included in de identified or aggregated datasets, or retained by recipients before withdrawal unless required by law or program terms.
Unless a program states a shorter period or I withdraw earlier, this Consent remains effective for five years from acceptance or signature. Different expiration: ____________________________________________.
8. Acknowledgment
By signing or accepting electronically, I confirm that I have read this Consent and understand that participation is optional. I authorize Alpine Labs to use and disclose information for selected program types, subject to specific program details and my consent choices.
Signature
Signature
Printed Name
Date
Representative Name, if applicable